1
|
Colonna S, Casacci F, Borghi C. Scoliosis and Lower Limb Inequality: To Lift or Not to Lift, That Is the Question. Cureus 2024; 16:e58443. [PMID: 38633141 PMCID: PMC11022167 DOI: 10.7759/cureus.58443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 04/19/2024] Open
Abstract
In subjects with scoliotic alterations of the spine, asymmetrical lengths of the lower limbs are frequently observed, a condition commonly referred to as leg length inequality (LLI) or discrepancy (LLD). This asymmetry can induce pelvic misalignments, manifested by an asymmetric height of the iliac crests, and consequently an alteration of the spine's axis. Although correcting this discrepancy might appear to be a straightforward solution, further investigation may reveal other indications. The purpose of this article is to aid clinicians confronted with the decision of whether to compensate for an LLI in individuals with scoliosis, encompassing both adolescents and adults. It presents a literature review on the incidence of LLIs in the general population, distinguishing between structural LLI (sLLI) and functional LLI (fLLI) types of LLIs, and quantifying their magnitude with clinical and instrumental evaluation. Additionally, it links these two types of LLIs to the type of scoliosis (structural or functional). From a clinical perspective, it also examines the compensatory mechanisms employed by the pelvis in the presence of structural or functional LLIs in order to draw useful indications for therapeutic decisions. Moreover, it proposes an additional evaluation parameter in the coronal plane, namely the central sacral vertical line (CSVL), to aid in the decision-making process regarding LLI compensation. Although this parameter has been documented in the literature, it has been little associated with LLIs. The findings indicate that scoliotic discrepancies should be compensated (conservatively or surgically) only when the imbalance of the femoral heads is on the same side as the imbalance of the sacrum and the iliac crests; this corrective action should result in a reduction of the overhang in the coronal plane.
Collapse
Affiliation(s)
- Saverio Colonna
- Rehabilitation Medicine, Spine Center, Bologna, ITA
- Research and Development, Osteopathic Spine Center Education, Bologna, ITA
| | - Fabio Casacci
- Rehabilitation Medicine, Spine Center, Bologna, ITA
- Research and Development, Osteopathic Spine Center Education, Bologna, ITA
| | - Corrado Borghi
- Rehabilitation Medicine, Spine Center, Bologna, ITA
- Research and Development, Osteopathic Spine Center Education, Bologna, ITA
| |
Collapse
|
2
|
Wu J, Zhuang X, Lin C, He L, Zhang R. Does the use of intraoperative measurement reduce limb length discrepancies after total hip arthroplasty? BMC Musculoskelet Disord 2023; 24:648. [PMID: 37573304 PMCID: PMC10423409 DOI: 10.1186/s12891-023-06774-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023] Open
Abstract
PURPOSE Postoperative limb length discrepancy (LLD) is a common complication of total hip arthroplasty, and several methods exist to prevent LLD, but each has its benefits and drawbacks. The study investigates the application of intraoperative lower limb length measurement in preventing postoperative LLD. METHODS This study retrospectively analyzed 70 patients who underwent total hip arthroplasty from October 2018 to July 2022. The length of the lower limb on the operated side was measured intraoperatively using a sterilized paper ruler after the fitting of the trial mould and compared with the healthy side. Then the prosthesis size, depth and neck length were adjusted accordingly. RESULTS The absolute value of postoperative LLD was found to be 6.68 ± 4.48 mm, of which 53 cases (75.7%) were less than or equal to 10 mm, while 30 patients (42.9%) were less than or equal to 5 mm. CONCLUSION The use of intraoperative measurement is effective in reducing LLD after total hip arthroplasty.
Collapse
Affiliation(s)
- Junzhe Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian, 362000, China
| | - Xunrong Zhuang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian, 362000, China
| | - Chaohui Lin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian, 362000, China
| | - Lijiang He
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian, 362000, China
| | - Rongmou Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian, 362000, China.
| |
Collapse
|
3
|
Xie R, Huang J, Wu Q, Qian Y, Jiang D, Li L, Huang L. A Comparison of Radiographic Outcomes after Total Hip Arthroplasty between the Direct Lateral Approach and Posterior Lateral Approach with EOS 2D/3D X-Ray Imaging System. Orthop Surg 2023; 15:1312-1324. [PMID: 37076774 PMCID: PMC10157717 DOI: 10.1111/os.13726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE The classical approaches for total hip arthroplasty (THA) are the direct lateral approach (DLA) and posterior lateral approach (PLA). There are few studies comparing implant orientation with these two approaches, and the impact of surgical approaches on implant orientation remains controversial. With the rise of the EOS imaging system, we aimed to use it to identify the differences between and factors associated with implant orientation after THA using DLA and PLA. METHODS In our department from January 2019 to December 2021, 321 primary unilateral THAs that used PLA and DLA were enrolled. A total of 201 patients who received PLA and 120 patients who received DLA were included in this study. Two blinded observers measured each case using EOS imaging data. Postoperative imaging metrics and other relevant influencing factors of the two surgical approaches were compared. Postoperative imaging metrics, including the anteversion and inclination of the cup, anteversion of the stem, and combined anteversion were measured based on EOS. Other relevant influencing factors included age, approach, gender, laterality, BMI, anterior pelvic plane inclination, femoral head diameter, femoral offset, lateral pelvic tilt, pelvic incidence, pelvis axial rotation, sacral slope, sagittal pelvic tilt, and surgery time. Multiple linear regression analyses were performed to identify the predictors of acceptability for each imaging data point. RESULTS No dislocation was found in the 321 patients who underwent primary THA during this period. The mean anteversion and combined anteversion of the cups using the DLA were 21.33° ± 17.31° (-51.7°-60.8°) and 33.71° ± 20.85° (-38.8°-77.6°) and PLA were 25.34° ± 12.76° (-5.5°-57.0°) and 42.37° ± 18.85° (-8.7°-84.7°), respectively. The DLA group had smaller anteversion (p = 0.038) and combined anteversion (p < 0.001). We found that surgical approach (p < 0.05), anterior pelvic plane inclination (p < 0.001), gender (p < 0.001), and femoral head diameter (p < 0.001) were important factors affecting acetabular cup anteversion (R2 = 0.375) and combined anteversion (R2 = 0.525). CONCLUSIONS In total hip arthroplasty, different prosthesis installation directions should be made according to different surgical approaches. Compared with the direct lateral approach, the acetabular anteversion can be intentionally enlarged when using the posterolateral approach. Surgical approach, anterior pelvic plane inclination (APPI), gender, and femoral head diameter were significant predictors of prosthesis orientation. The anterior pelvic plane inclination may be a useful standard for assessing the position of the prosthesis using EOS.
Collapse
Affiliation(s)
- Rui Xie
- Department of Orthopaedic SurgeryThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Jun Huang
- Department of Orthopaedic SurgeryThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Qian Wu
- Department of Orthopaedic SurgeryThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Yu‐fan Qian
- Department of Orthopaedic SurgeryThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Dinghua Jiang
- Department of Orthopaedic SurgeryThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Lisong Li
- Department of Orthopaedic SurgeryThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Lixin Huang
- Department of Orthopaedic SurgeryThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| |
Collapse
|
4
|
Hardwick-Morris M, Wigmore E, Twiggs J, Miles B, Jones CW, Yates PJ. Leg length discrepancy assessment in total hip arthroplasty: is a pelvic radiograph sufficient? Bone Jt Open 2022; 3:960-968. [PMID: 36510730 PMCID: PMC9783271 DOI: 10.1302/2633-1462.312.bjo-2022-0146.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS Leg length discrepancy (LLD) is a common pre- and postoperative issue in total hip arthroplasty (THA) patients. The conventional technique for measuring LLD has historically been on a non-weightbearing anteroposterior pelvic radiograph; however, this does not capture many potential sources of LLD. The aim of this study was to determine if long-limb EOS radiology can provide a more reproducible and holistic measurement of LLD. METHODS In all, 93 patients who underwent a THA received a standardized preoperative EOS scan, anteroposterior (AP) radiograph, and clinical LLD assessment. Overall, 13 measurements were taken along both anatomical and functional axes and measured twice by an orthopaedic fellow and surgical planning engineer to calculate intraoperator reproducibility and correlations between measurements. RESULTS Strong correlations were observed for all EOS measurements (rs > 0.9). The strongest correlation with AP radiograph (inter-teardrop line) was observed for functional-ASIS-to-floor (functional) (rs = 0.57), much weaker than the correlations between EOS measurements. ASIS-to-ankle measurements exhibited a high correlation to other linear measurements and the highest ICC (rs = 0.97). Using anterior superior iliac spine (ASIS)-to-ankle, 33% of patients had an absolute LLD of greater than 10 mm, which was statistically different from the inter-teardrop LLD measurement (p < 0.005). DISCUSSION We found that the conventional measurement of LLD on AP pelvic radiograph does not correlate well with long leg measurements and may not provide a true appreciation of LLD. ASIS-to-ankle demonstrated improved detection of potential LLD than other EOS and radiograph measurements. Full length, functional imaging methods may become the new gold standard to measure LLD.Cite this article: Bone Jt Open 2022;3(12):960-968.
Collapse
Affiliation(s)
- Max Hardwick-Morris
- 360 Med Care, Sydney, NSW, Australia,Flinders University, Adelaide, SA, Australia,Correspondence should be sent to Max Hardwick-Morris. E-mail:
| | - Estelle Wigmore
- 360 Med Care, Sydney, NSW, Australia,Flinders University, Adelaide, SA, Australia
| | | | | | - Christopher W. Jones
- Curtin University Faculty of Health Sciences, School of Medicine, Perth, WA, Australia,Orthopaedics WA, Murdoch, WA, Australia,Fiona Stanley Hospital, Murdoch, WA, Australia,St. John of God Murdoch Hospital, Murdoch, WA, Australia,Orthopaedic Research Foundation of Western Australia, Perth, WA, Australia
| | - Piers J. Yates
- Orthopaedics WA, Murdoch, WA, Australia,Fiona Stanley Hospital, Murdoch, WA, Australia,St. John of God Murdoch Hospital, Murdoch, WA, Australia,Orthopaedic Research Foundation of Western Australia, Perth, WA, Australia,University of Western Australia, Faculty of Medicine, Dentistry and Health Sciences, Perth, WA, Australia
| |
Collapse
|
5
|
Tibia Multiplanar Deformities and Growth Disturbance Following Expandable Endoprosthetic Distal Femur Replacement. J Clin Med 2022; 11:jcm11226734. [PMID: 36431210 PMCID: PMC9699560 DOI: 10.3390/jcm11226734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/29/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Expandable distal femur endoprosthesis (EDFE) is commonly used to compensate for the loss of the distal femoral epiphyseal plate in skeletally immature children who have undergone surgical resection of bone malignancies. However, the effect of the passive tibial component of the EDFE on tibial growth has not been extensively studied in the literature. This study aims to delineate the type, frequency, and associated risk factors of multiplanar proximal tibial deformities in skeletally immature children following the use of the expandable distal femur endoprosthesis (EDFE). Moreover, we plan to detect how these deformities influence the long-term functionality of the endoprosthesis in defining the need for subsequent implant revision or further surgical management. Patients and Methods: A total of 20 patients aged (7−12) years underwent expandable distal femur replacement. Two types of implants were used: Juvenile Tumor System (JTS) non-invasive prosthesis in 14 patients, and Modular Universal Tumor and Revision System (MUTARS)® Xpand Growing Prostheses in six patients. A scanogram and CT scan documented the measurements of longitudinal and multiplanar growth as leg length discrepancy (LLD), femur length discrepancy (FLD), tibia length discrepancy (TLD), and the yield values of rotational, sagittal, and coronal deformities of the tibia. The patients were followed up to assess the need for further management. Sex, age, size of tibial plate perforation, and type of implant used were studied for possible correlation with deformities or growth disturbance. Results: The patients were followed up for a mean of 3 (2−7) years. A total of 14 patients, (10 JTS, 4 implant cast) had a tibial deformity and/or growth disturbance. A single patient was found to have all deformities (growth, rotational, coronal, and sagittal). Fourteen patients were found to have an LLD ranging from 5.3 to 59 mm (median 21 mm), 12 had a TLD from 3 to 30 mm, (median 10 mm), and 11 patients showed evidence of malrotation from 6 to 32 degrees (median 11 degrees). TLD was found to contribute entirely to LLD in three patients, and >50% of LLDs in seven patients. All LLDs were treated conservatively, except in three patients; two received contralateral tibia epiphysiodesis and one received revision with a new implant. A single patient had a posterior tibia slope angle (PTSA) of −2.8 degrees, and three patients had a coronal deformity with a mean medial proximal tibia angle (MPTA) of 80.3 (77−83 degrees). Conclusions: Tibial growth disturbance and multiplanar deformities occur in the majority of patients following EDFE replacement, exacerbating LLD. Yet, these disturbances may be well tolerated, managed conservatively, and rarely mandate endoprosthetic revision or subsequent corrective surgery. Age at the time of surgery was found to be the only significant contributor to the development of tibia growth disturbance.
Collapse
|
6
|
Imaging in Hip Arthroplasty Management-Part 1: Templating: Past, Present and Future. J Clin Med 2022; 11:jcm11185465. [PMID: 36143112 PMCID: PMC9503653 DOI: 10.3390/jcm11185465] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
Hip arthroplasty is a frequently used procedure with high success rates. Its main indications are primary or secondary advanced osteoarthritis, due to acute fracture, osteonecrosis of the femoral head, and hip dysplasia. The goals of HA are to reduce pain and restore normal hip biomechanics, allowing a return to the patient’s normal activities. To reach those goals, the size of implants must suit, and their positioning must meet, quality criteria, which can be determined by preoperative imaging. Moreover, mechanical complications can be influenced by implant size and position, and could be avoided by precise preoperative templating. Templating used to rely on standard radiographs, but recently the use of EOS® imaging and CT has been growing, given the 3D approach provided by these methods. However, there is no consensus on the optimal imaging work-up, which may have an impact on the outcomes of the procedure. This article reviews the current principles of templating, the various imaging techniques used for it, as well as their advantages and drawbacks, and their expected results.
Collapse
|
7
|
Imaging in Hip Arthroplasty Management Part 2: Postoperative Diagnostic Imaging Strategy. J Clin Med 2022; 11:jcm11154416. [PMID: 35956033 PMCID: PMC9369831 DOI: 10.3390/jcm11154416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 12/04/2022] Open
Abstract
Hip arthroplasty (HA) is a frequently used procedure with high success rates, but 7% to 27% of the patients complain of persistent postsurgical pain 1 to 4 years post-operation. HA complications depend on the post-operative delay, the type of material used, the patient’s characteristics, and the surgical approach. Radiographs are still the first imaging modality used for routine follow-up, in asymptomatic and painful cases. CT and MRI used to suffer from metallic artifacts but are nowadays central in HA complications diagnosis, both having their advantages and drawbacks. Additionally, there is no consensus on the optimal imaging workup for HA complication diagnosis, which may have an impact on patient management. After a brief reminder about the different types of prostheses, this article reviews their normal and pathologic appearance, according to each imaging modality, keeping in mind that few abnormalities might be present, not anyone requiring treatment, depending on the clinical scenario. A diagnostic imaging workup is also discussed, to aid the therapist in his imaging studies prescription and the radiologist in their practical aspects.
Collapse
|